The Most Urgent Medical Response In A Disaster: Stop The Bleeding

For more than three hours after the shooting began, Christopher Colwell stayed outside the building to triage victims, sending those with massive gunshot injuries straight to the Emergency Department and assessing others who’d sprained an ankle, hit their heads or suffered shrapnel wounds in the scramble to escape the hail of bullets.

Only when the scene was deemed safe was the 34-year-old ER doctor able to enter with a small SWAT team and a couple of police officers to perform the ritual of pronouncing people dead.

He pressed gloved fingers against victims’ necks – careful not to confuse the throb of his own adrenaline-fueled heartbeat with the reassuring woosh he hoped to feel of blood rushing up carotid arteries.

Most had been killed where they’d tried to take cover, from shots to the head, neck and chest, their young bodies now cooling and their blood beginning to pool as gravity takes over from a beating heart.

But one older man had staggered away from where he’d been hit and was still conscious for much of the time that Colwell was saving lives outside. When Colwell reached William “Dave” Sanders, the 47-year-old business teacher and basketball coach at Columbine High School in Colorado had bled to death.

In the 17 years of mass shootings and stalled debates about gun control that separate Columbine from the recent massacre in Orlando, Florida, another debate has evolved among medical professionals and first responders about how to prevent deaths like Sanders’s. It hovers over the decision in Orlando to wait three hours after Omar Mateen began shooting before breaching the Pulse nightclub where he was holding hostages and where unknown numbers were wounded. And it is an increasingly urgent focus for emergency responders, because one of the few comments experts make with confidence about these unpredictable mass attacks is that they are sure to happen again.

“Scoop and run” – the idea of moving victims to a trauma hospital as quickly as possible – is a mantra of modern U.S. emergency care. Internal hemorrhage can be handled only in an operating room. But stanching bleeding from arms and legs often needs to happen even sooner.

These days, law enforcement officers routinely enter active shooting scenes to stop the bloodshed rather than waiting for SWAT teams, as they did at Columbine. The medical examiner’s office in Orlando has not revealed whether any of the dead at Pulse could have been saved if the hostage standoff had ended and they had received medical care sooner.

A controversial question is what role paramedics and even physicians play in those dangerous, pre-hospital settings, where minutes can make the difference between life and death.

“The philosophy about how to handle these mass shooting events is much in flux,” said David King, a trauma surgeon and active member of the U.S. Special Operations community who operated on many of the Boston Marathon bombing victims at Massachusetts General Hospital in 2013 after running the race himself.

Some advocate keeping medical teams away from the scene until it is declared safe. Others believe in creating an intermediate “orange zone,” where paramedics dressed in protective gear can provide initial treatment. Still others favor a far more aggressive approach, sending in tactical medical personnel who are trained, like King, to handle guns as well as tourniquets to stop bleeding and needles to decompress punctured lungs.

Nobody knows the answer, King says. There is no standard procedure recommended by the American College of Surgeons. And even if there were, he says, the decision of whether to send medical experts into an active “red zone” probably would rest with the mayor or police chief of whatever unsuspecting community had been assaulted, like Orlando, by a shooter armed with a high-velocity weapon and many rounds of ammunition.

Educating the public

Bleeding to death, or exsanguination, has long been a leading cause of death for troops on the battlefield. And it can happen very quickly. The human body contains about 10 pints of blood. The heart beats about 70 times per minute, pumping the oxygen-rich liquid out through arteries to feed the brain and the body’s extremities, before it returns via veins to be replenished. A gunshot wound to a major vessel, such as the femoral artery in the thigh, causes blood to spurt out rapidly under pressure. Death takes less than five minutes. Slower bleeding also can be perilous, leading to a downward spiral known as the “bloody vicious cycle” when the blood loses its ability to clot.

One study found that 25 percent of battlefield deaths were “potentially survivable,” and that of those, 90 percent were bleed-outs.

Hence the reintroduction of the tourniquet, a device that has been around since Roman times but fell out of favor because of concerns that its prolonged use caused limb loss. Today, with swift evacuation times, the tourniquet is a lifesaver for troops. Every soldier carries one. And often two.

Bleeding out is far less common among civilian populations, but still accounts for more than 35 percent of pre-hospital deaths after a traumatic injury. And mass shootings, and other acts of terrorism such as the Boston Marathon bombing, cause injuries and challenges in rescuing survivors that resemble warfare. A report released June 17 by the National Academies said that up to 20 percent of U.S. trauma deaths could be prevented and urged the translation of wartime lessons to civilian systems, particularly in pre-hospital settings. Just as in the treatment of burns, the battlefield is a valuable training ground for civilian hemorrhage care.

Tourniquets are now available in many ambulances. And emergency treatment priorities have been flipped, says Eric Goralnick, an emergency medicine physician and former Navy office at Boston’s Brigham and Women’s Hospital. The ABCs of emergency care – airway, breathing and circulation – are now CAB, Goralnick says, putting the circulatory system first.

Less clear is who provides pre-hospital care – and where. Michael Neeki, an attending physician at Arrowhead Regional Medical Center in California who volunteers with a SWAT team, believes in “trying to introduce more [medical] capabilities into the field.” Neeki headed to the scene of the December 2015 shootings in San Bernardino, Calif., carrying a handgun, 10 tourniquets and sophisticated medical equipment to join the search for the shooters in the Inland Regional Center where 14 people died.

There is also a move to equip members of the public with knowledge and tools to help. Immediately after the Boston Marathon bombing, King, the Mass General surgeon, raced to the hospital still dressed in his running clothes to find victims arriving with tourniquets fashioned from belts and T-shirts, from shoelaces and pieces of rubber tubing. Most improvised tourniquets don’t work well, he says. They can’t be pulled tight enough to prevent arterial bleeding and can cause damage by stopping the flow of blood back to the heart through veins.

Still, King emphasizes the critical role fellow victims or bystanders can play. He has trained teachers in the school his children attends in the use of tourniquets. He helped make sure the devices were available along the course of the 2014 Boston Marathon. And he contributed to the 2015 Hartford Consensus, a call to action spurred by the shootings at Sandy Hook Elementary School in Newtown, Connecticut, where 20 children and six staff members were killed in December 2012.

A joint effort by physicians, nurses, law enforcement officials and emergency services, the consensus argues “that in intentional mass-casualty and active shooter events, no one should die from uncontrolled bleeding.” It reclassifies bystanders as “immediate responders” and advocates for tourniquets to be made available – much like defibrillator – in shopping malls and museums, in schools and theaters, and in train stations and airports.

As a result, in October 2015, the Obama administration began a campaign to educate the public on hemorrhage control.

It’s called “Stop the Bleed.”

“The biggest lesson since Columbine has been the value of the tourniquet,” says Colwell, now chief of emergency medicine at Denver Health.

But he says the device wouldn’t have helped Sanders, who was shot in the back and the neck, where tourniquets can’t be applied, and he’ll never know whether the teacher would have lived even if he’d been quickly removed. Gunshot wounds can be unpredictable, Colwell says. And “it’s hard to overstate the damage” done by high-velocity weapons, where a small entry wound can disguise massive internal injuries. But he says he has a “pretty good idea” that some wounds he saw that day in April 1999 “would have been survived under different circumstances.”

Seeking to offer something positive from his experience, Colwell began lecturing about what he learned first at Columbine and then in 2012, when he was working in the ER after a gunman opened fire in a movie theater in Aurora, Colorado. Similarly, Goralnick is currently in Europe to help identify best practices in after-attack care, with support from a fund set up by the family of an 18-year-old dancer whose legs were injured following the Boston Marathon bombing. Goralnick is comparing strategies used in Boston, Brussels and Paris, where emergency response is very different from that in the United States, and French doctors performed extensive care in makeshift facilities close to the site of the November shootings.

Those sessions are part of an increasingly urgent attempt to gather and analyze evidence from civilian attacks and warfare to ensure that the medical response to mass attacks continues to improve as it has done in the 17 years since the Columbine massacre.

“We ended up waiting much longer to access the scene than we would today,” Colwell recalls of that early shooting. “But I don’t think that was necessarily a bad decision based on the knowledge we had then.”